Author Question: Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal ... (Read 45 times)

Caiter2013 · **on:** Jul 23, 2018

Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal and ethical standards is shown when:

1. Charting the client's response to pain medication taken.
2. Describing the client as appearing to be comfortable.
3. Leaving sufficient charting space for the previous shift to chart client teaching.
4. Documenting that the client reports, I'm so afraid of tomorrow's surgery.
5. Making a late entry regarding a client's request for pain medication.

Question 2

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, this information would be included in the section identified as:

1. Data (D).
2. Action (A).
3. Response (R).
4. Planning (P).

flexer1n1 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1,4,5
Rationale 1: Documentation guidelines include charting a change in a client's condition and showing that follow-up actions were taken.
Rationale 2: Documentation guidelines include not using vague terms (e.g., appears to be comfortable).
Rationale 3: Documentation guidelines include not leaving a blank space for a colleague to chart later.
Rationale 4: Documentation guidelines include recording the client's actual words by putting quotation marks around the words.
Rationale 5: Documentation guidelines include the idea that a late entry is better than no entry.
Global Rationale:

Answer to Question 2

Correct Answer: 3
Rationale 1: The data (D) section reflects the assessment phase of the nursing process, and consists of observations of client status and behaviors, including data from flow sheets.
Rationale 2: The action (A) category reflects planning and implementation, and includes immediate and future nursing action.
Rationale 3: The response (R) category reflects the evaluation phase of the nursing process, and describes the client's response to any nursing and medical care.
Rationale 4: Planning is a subcategory of Action (A).